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The Juilliard School Fall 2021 Health and Counseling Services 60 The Juilliard School Fall 2021 Health and Counseling Services 60 Lincoln Center Plaza New York, NY 10023 Phone: 212-799-5000 Ext 282 Email: [email protected] Dear New Juilliard Student: Welcome to Juilliard. We look forward to meeting you and providing you with high-quality health care while you are a student. In order to accomplish this, we must have a comprehensive health history, including a record of all immunizations (or documentation of serological immunity) and the completed Tuberculosis Screening Form. All documentation must be in English. Please make a back-up copy of all completed forms. The completed health form must be returned to the Health Services office by August 1, 2021. You will not be able to register for classes on time without completion of these forms. Please begin this form as soon as possible. It is required in New York State to provide incoming college students with information about meningitis. Meningitis is a very serious disease that has affected campuses across the nation. Please carefully read the enclosed information and discuss with your family and your health care practitioner the advisability of getting the vaccination. If you decide you want the protection of the vaccine, we strongly advise you to get it before you arrive at school. Juilliard requires all students living on-campus in the Residence Hall to receive the Meningococcal Meningitis ACWY vaccine. We strongly encourage you to complete all of the routine childhood vaccinations prior to your enrollment. College students do contract these diseases resulting in serious illness and prolonged absence from class. Additionally, we recommend that you take advantage of the free influenza vaccines that are offered to students annually. You will receive a notice in the Fall about when the flu shots are available. While the rate of COVID-19 infections in New York City is currently lower than in many metropolitan areas of the United States, it remains a serious public health issue. It is highly recommended that all incoming students be vaccinated against virus as soon as they are eligible. Juilliard Health and Counseling Services provide free primary health care and psychological services to all enrolled students at the school. Health Services provides medical treatment and preventative care, as well as Physical Therapy, Occupational Therapy, Chiropractic and Nutrition services to aid students in performing their best. Counseling Services provides supportive psychotherapy to assist students in meeting their emotional, psychological, and mental health needs. More information about our services is available on the Juilliard website https://www.juilliard.edu/campus-life/well-being/health-and-counseling-services . Students who are currently under the care of a mental health practitioner, and want to continue with psychotherapy and/or medication at school, should acquaint themselves now with the Juilliard Counseling Service. The Counseling Service provides free weekly counseling sessions to students and there is a staff psychiatrist available for prescribing medication. Counseling Service’s phone number is 212-769-3918. Please do not hesitate to contact us if you have any questions about the enclosed forms, or about the services provided at the Juilliard Health and Counseling Services. Be sure to send completed health forms directly to Health Services, not to Admissions, and do not combine them with any other form that you are returning to Juilliard. (Health Insurance forms go to the Student Accounts Office.) We look forward to meeting you and providing you with excellent primary and mental health care. Sincerely, Beth Techow, Administrative Director Health and Counseling Services 1 Health & Immuniz/ Health Record 2021-22 The Juilliard School Fall 2021 Health and Counseling Services 60 Lincoln Center Plaza New York, NY 10023 Phone: 212-799-5000 Ext 282 Email: [email protected] STUDENT HEALTH RECORD INSTRUCTIONS CHECKLIST: Completed Health Record is due Aug. 1, 2021. Please send in the forms after all of the following are COMPLETE: 1. Parts I, II, and VI, your personal information, history and consent for care. If you are under age 18, your parent or legal guardian must sign Parts V & VI. 2. Your healthcare provider has completed and signed Part III (Immunization History) and returned the form to you. 3. Part IV, the Tuberculosis Screening Form. If the answer is “yes” to any of the questions, the Tuberculosis Risk Assessment must be completed and signed by a healthcare provider and the TB skin test (page 11,#2) or blood test (page 11, #3) must be performed within 12 months prior to arrival at School. 4. Part V, Meningococcal Meningitis Vaccination Response Form, required by New York State law. The Meningococcal Meningitis vaccine ACWY is required of all students living on-campus in the Residence Hall. 5. MAKE A PHOTOCOPY OF THIS COMPLETED FORM AND BRING THE COPY TO SCHOOL WITH YOU IN CASE THE ORIGINAL FORM GETS LOST AND NEEDS TO BE RESUBMITTED. 6. We must receive this form by August 1, 2021. Choose one of the following: Preferred: Upload this original and signed form through the secure Student Health Portal at: www.juilliard.edu/studenthealth (you may access this AFTER you receive your Juilliard email address) Email to [email protected] or Mail this original and signed form to the above address. Health & Immuniz/ Health Record 2021-22 2 The Juilliard School Fall 2021 Health and Counseling Services 60 Lincoln Center Plaza New York, NY 10023 Phone: 212-799-5000 Ext 282 Email: [email protected] PART I—STUDENT’S DEMOGRAPHICS Name: _______________________________________________________________________ (Last) (First) (Middle) Birth Date: (M/D/Y) _____/_____/ ______ Gender: _________________________________________ Juilliard Division: Music Dance Drama If music, please indicate instrument:__________________________ Are you a Juilliard graduate? _____________If YES, what month /year did you graduate? _____/______ Will you live in the Juilliard Residence Hall? No Yes Not sure Permanent Address:_________________________________________________________________________ _________________________________________________________________________________________ City State Zip Country Phone: __________________________ Cell phone: __________________________ E-Mail address: _____________________________________________________________________________ Name of Parent(s), Spouse, or Guardian (check one):__________________________________________ Address: __________________________________________________________________________________ __________________________________________________________________________________________ City State Zip Country Telephone: Home: ________________________________ Work: _______________________________ Cell: _______________________________ E-Mail address: _____________________________________ Emergency Contact (if a different person than parent, spouse, or guardian listed above) Name: _______________________________________________Relationship to you:_____________________ Address: __________________________________________________________________________________ __________________________________________________________________________________________ City State Zip Country Telephone: Home: ________________________________ Work: _______________________________ Cell: _______________________________ E-Mail address: _____________________________________ Healthcare Provider/Clinic that you usually consult for medical care: Name: ____________________________________________________________________________________ Address: __________________________________________________________________________________ __________________________________________________________________________________________ City State Zip Country Telephone: ________________________________ Over Health & Immuniz/ Health Record 2021-22 3 The Juilliard School Fall 2021 Health and Counseling Services 60 Lincoln Center Plaza New York, NY 10023 Phone: 212-799-5000 Ext 282 Email: [email protected] PART II —STUDENT’S FAMILY HISTORY Student’s Name: _________________________________________________ Family History Year of Birth Occupation Health If deceased, specify Good /Fair/ Cause and Age at Death Poor Mother Father Brothers Sisters IS THERE A HISTORY OF SIGNIFICANT ILLNESSES IN YOUR FAMILY? Check each item No Yes Who? Check each No Yes Who? item Alcohol or drug High Blood problems/abuse Pressure Asthma Kidney Disease Cancer, leukemia, or Migraine lymphoma High Cholesterol Stroke Diabetes mellitus Sudden death under age 50 Emotional/Psychological Tuberculosis problems Heart attack, disease, or Other—please problem specify Hypermobility/joint looseness Over Health & Immuniz/ Health Record 2021-22 4 The Juilliard School Fall 2021 Health and Counseling Services 60 Lincoln Center Plaza New York, NY 10023 Phone: 212-799-5000 Ext 282 Email: [email protected] PART II B—PERSONAL HEALTH HISTORY Student’s Name: _________________________________________________ 1 . Do you have allergies/adverse reactions to medications/food/insects/other? No Yes—please specify...______________________________________________________________ 2 . Do you take any medications on a frequent or regular basis? No Yes Please list ALL prescription AND nonprescription medications AND supplements: Name Dose Reason for taking __________________________________________________________________________________________ __________________________________________________________________________________________
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